Ascaris acute pancreatitis
Introduction
Introduction to aphid acute pancreatitis Ascaris-induced acute pancreatitis (ascaris-inducedacutepancreatitis) is relatively rare in clinical practice. The cause of the disease is a series of chemical inflammations of the pancreas caused by aphids entering the ampulla or pancreatic duct, which is caused by bile and pancreatic juice discharge. The clinical types are usually acute. In patients with edematous pancreatitis, some patients may develop hemorrhagic necrotizing pancreatitis. basic knowledge The proportion of children: the incidence rate of children is about 0.004%-0.007% Susceptible people: no specific population Mode of infection: fecal-mouth transmission Complications: chronic pancreatitis diabetes pancreas abscess abdominal pain sepsis gastrointestinal bleeding diffuse intravascular coagulation adult respiratory distress syndrome
Cause
Aphid-induced acute pancreatitis
(1) Causes of the disease
It is a series of pancreatic chemical inflammation caused by aphids entering the ampulla or pancreatic duct, which causes obstruction of bile and pancreatic juice. The clinical type is usually acute edematous pancreatitis, and some patients can develop hemorrhagic necrotizing pancreatitis.
(two) pathogenesis
There are two forms of digestive enzymes secreted by the pancreas, active digestive enzymes and inactive digestive enzymes or precursors. The former includes amylase, lipase and ribonuclease, the latter has trypsinogen and chymotrypsinogen. Pre-phospholipase, pre-elastase, kallikrein and pro-hydroxypeptidase. Under normal conditions, pancreatic juice enters the duodenum and is activated by enterokinase. Trypsinogen is first activated and formed. Trypsin and trypsin initiate a cascade of activation of various zymogens. After activation, various digestive enzymes digest food. After the aphids enter the pancreatic duct, the pancreatic juice and bile flow are blocked, and the pressure in the pancreaticobiliary tube rises. A digestive enzyme is activated, and the pancreas itself undergoes a digestive chain reaction. Among them, phospholipase A2, elastase, kallikrein, lipase or vasopressin and prolase, phospholipase A2 A small amount of bile participates in the decomposition of phospholipids in the cell membrane, producing lysophosphatidylcholine and lysophosphatidylcholine, its cytotoxic effect causes coagulative necrosis and adipose tissue necrosis of pancreatic parenchyma And hemolysis; elastase dissolves vascular elastic fibers to cause hemorrhage and thrombosis; kallikrein causes vasodilation and permeability to cause edema and shock; lipase participates in necrosis and liquefaction of pancreas and surrounding adipose tissue, digestive enzymes and various Necrotic tissue fluid can cause multiple organ damage through the blood and lymph circulation to the whole body, which is the cause of death and various complications of pancreatitis. Recent studies have shown that there are many inflammatory mediators involved in the pathological process of acute pancreatitis, such as oxidative Nitrogen, oxygen free radicals, platelet activating factor, prostaglandins, leukotrienes, etc. can act on various pathological steps of pancreatitis, causing disorders of the blood circulation of the pancreas and participating in the occurrence and development of inflammation.
Prevention
Aphid prevention of acute pancreatitis
Implementing harmlessness of feces and developing good habits of personal hygiene and food hygiene, and strengthening the survey of susceptible populations, especially in rural areas, if it is found that the parasitic infection rate of aphids and other parasites exceeds 60%, deworming treatment can be reduced. The occurrence of aphid pancreatitis.
Complication
Aphid acute pancreatitis complications Complications Chronic pancreatitis Diabetic pancreas abscess Abdominal pain Septic bleeding Digestive endovascular coagulation Adult respiratory distress syndrome
Divided into local complications, systemic complications, multiple organ failure, chronic pancreatitis and diabetes, local complications manifested as pancreatic abscess or pancreatic cyst, the former more than 2 to 3 weeks of the course of the disease, manifested as high fever, abdominal pain, poisoning Symptoms and upper abdomen mass; pancreatic cysts formed more than 3 to 4 weeks of disease, can cause adjacent symptoms caused by compression of adjacent tissues, systemic complications are often sepsis or double infection (fungal infection) and gastrointestinal bleeding; multiple organ failure can be It is characterized by renal failure, heart function and other organ failures, as well as diffuse intravascular coagulation and adult respiratory distress syndrome.
Symptom
Aphid-like acute pancreatitis symptoms Common symptoms Abdominal muscle tension Abdominal tenderness Abdominal pain Nausea bowel death Hypotension Aphid infection Pancreatic abdominal pain Mania
The clinical manifestations of the patients are related to the etiology, pathological type and timely diagnosis and treatment. Very few patients may have sudden death.
Symptom
(1) Abdominal pain: almost all patients have abdominal pain, most of them are upper abdomen, multi-directional lumbar back radiation, accompanied by nausea and vomiting, pain can be expressed as heart-like or cramping, can continue for many hours or even days, nausea Vomiting and changes in body position and general gastrointestinal antispasmodic drugs can not alleviate the symptoms of abdominal pain, cough, deep breathing can aggravate abdominal pain.
(2) nausea and vomiting and bloating: more often after onset, manifested as vomiting stomach food and bile, sometimes patients can vomit mites into adult worms, patients with bloating symptoms, and even paralytic ileus.
(3) Fever: Most patients have moderate or higher fever, usually lasting 3 to 5 days. If the patient's body temperature lasts for more than 1 week or the body temperature gradually rises with leukocyte elevation, be alert to secondary infections such as pancreatic abscess or biliary infection. Wait.
(4) hypotension or shock: mainly seen in hemorrhagic necrotizing pancreatitis, a small number of patients can occur suddenly, but also gradually appear after other complications, mainly effective blood volume deficiency, bradykinin caused by peripheral vasodilation, pancreatic necrosis Releases myocardial inhibitory factor, concurrent with infection or gastrointestinal bleeding.
(5) water and electrolyte and acid-base balance disorder: patients may have metabolic alkalosis due to frequent vomiting, often varying degrees of dehydration, severe dehydration and metabolic acidosis, with blood potassium, blood calcium , blood magnesium is reduced.
(6) Others: Patients with acute and severe illness may have acute respiratory failure or adult respiratory distress syndrome. Patients may also experience other organ failure such as renal function and heart failure. Some patients have pancreatic encephalopathy, which is characterized by mental abnormalities and confusion. Lack of orientation, accompanied by fantasies, hallucinations and mania.
2. Signs
Acute edematous pancreatitis patients with mild abdominal signs, often inconsistent with the patient's complaint, because the pancreas is caused by the posterior peritoneal organs, patients with upper abdominal tenderness, no rebound and muscle tension, may be associated with bloating and bowel sounds Less, hemorrhagic necrotic pancreatitis often appears acute peritonitis signs, that is, abdominal muscle tension, abdominal tenderness and rebound tenderness, with bowel sounds weakened or disappeared with paralytic ileus, some patients have ascites, mostly bloody ascites, Abdominal mobility dullness is positive. A few patients can see the Grey-Turner sign and the Gullen sign, because pancreatic enzymes, necrotic tissue and hemorrhage penetrate into the abdominal wall along the peritoneal space and muscle layer, respectively, and the skin color changes on both sides of the rib abdomen and umbilicus, respectively. In patients with pancreatic abscess or pancreatic cyst, the upper abdomen can be paralyzed and massed. The early jaundice is caused by pancreatic head inflammatory edema, obstruction of common bile duct or ampullary mites, and later jaundice is mostly pancreatic abscess or cyst compression of common bile duct or hepatocyte damage. Cause, severe pancreatic necrosis after calcification caused by hypocalcemia, clinical manifestations of hand and foot convulsions.
Examine
Examination of aphid acute pancreatitis
White blood cell count
There is leukocytosis and neutrophil nucleus left shift.
2. Amylase assay
There are two types of amylase in the blood of normal people, namely saliva type and pancreatic type. The amylase which is elevated in acute pancreatitis is mainly pancreatic type. The rapid swab used in clinical practice can inhibit salivary amylase in serum and only detect pancreatic type. Amylase, therefore, has a high specificity. Serum amylase starts to rise 6 to 12 hours after onset, and begins to decline at 48 hours. For several days, serum amylase is more than 5 times normal to confirm the disease. It is worth noting that The level of serum amylase is not necessarily parallel with the patient's condition. The amylase of hemorrhagic necrotizing pancreatitis may be lower than normal or normal. Other diseases such as acute gastrointestinal perforation, acute cholecystitis, cholelithiasis, serum starch in acute intestinal obstruction. The enzyme can rise, but generally does not exceed 2 times of normal, the increase of urinary amylase is about 6h later than the increase of serum amylase, and it is greatly affected by the urine volume of the patient.
3. Amylase, endogenous creatinine clearance ratio (cam/ccr%)
The clinical normal value of Cam/ccr% is 1% to 4%. In acute pancreatitis, the removal of creatinine by the increase of amylase in the kidney is unchanged, which causes the increase of this ratio, which is usually increased by 3 times. This value is generally normal or below normal in serum hyperamylasemia, but this ratio can be elevated in patients with diabetic ketosis and renal insufficiency.
4. Serum lipase
The elevated time of serum lipase was about 24 hours later than the increase of serum amylase, and the duration was longer than that of serum amylase. It was used for the diagnosis of patients with late treatment.
5. Serum methemoglobin
When the patient has intra-abdominal hemorrhage, hemoglobin in red blood cells can form positive iron albumin after a series of changes, which can occur 72 hours after onset, and the positive indicates that the patient is severe hemorrhagic necrotizing pancreatitis.
6. Biochemical examination
Patients have temporary elevated blood glucose, and return to normal after more than 3 to 5 days. If the patient's blood glucose continues to rise above 10mmol/L, it indicates severe pancreatic necrosis and poor prognosis. Clinical tests for transaminase and lactate dehydrogenase are also performed. Can be common, and often have temporary hypocalcemia, such as patients with blood calcium below 1.75mmol / L and hand and foot convulsions also indicate hemorrhagic necrotizing pancreatitis; such as patients with PaO2 less than 60mmHg, clinical caution for adult respiratory distress synthesis The appearance of the sign.
7. Abdominal plain film: Other acute abdomen such as perforation can be excluded, and intestinal paralysis or diagnosis of paralytic ileus can also be found.
8. Abdominal B-ultrasound: B-ultrasound has a diagnostic significance for pancreatic enlargement, pancreatic abscess and pancreatic pseudocyst. When the aphid blocks the pancreatic duct, a solid parallel light band is visible in the pancreatic duct, and there is no sound and shadow behind. No obvious light creeps in the light band.
9. CT: CT examination can clearly show the lesions of the pancreas and its surrounding organs due to the influence of gas in the intestinal lumen, and can distinguish between edema and necrotic pancreatitis and its severity.
10. Endoscopy: In the past, emergency endoscopy was included as a contraindication for acute pancreatitis. At present, this view has changed. Endoscopy can find that the mites block the pancreatic duct and can be taken out, especially for elderly patients. Patients who cannot tolerate surgery are especially suitable.
Diagnosis
Diagnosis and identification of aphid acute pancreatitis
According to the patient's typical clinical manifestations and laboratory tests, plus B-ultrasound found in the pancreatic duct visible strip-shaped echogenic band, the diagnosis of aphid pancreatitis can be made.
Differential diagnosis
1. Peptic ulcer perforation: The patient has a history of typical ulcer disease, sudden onset of abdominal pain, physical examination of the liver dullness disappears, X-ray or abdominal plain film can be seen under the armpit free gas, can be identified.
2. Acute cholecystitis, cholelithiasis: The patient has a history of biliary colic in the past, the pain is located in the right upper abdomen, the Murphy sign is positive, B-ultrasound and gallbladder angiography can be identified.
3. Acute intestinal obstruction: patients with paroxysmal abdominal pain and nausea and vomiting, stop defecation and exhaust, abdominal plain film can be identified by liquid and gas plane.
4. Acute myocardial infarction: a history of coronary heart disease, sudden onset, typical electrocardiogram and dynamic progression of myocardial zymogram can be identified.
